Care Home: Beechey House

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What the care home does well The home carries out pre-admission assessments of need for people who wish to move to the home, to make sure that these can be met at the home. Residents` health and social needs are met through good care planning and risk assessment. The home works closely with health colleagues. Medication is administered in line with good practice. Residents are treated with respect and dignity.Beechey HouseDS0000064864.V376732.R01.S.docVersion 5.2Residents can receive visitors at any time. The home provides a good standard of food. The home has well publicised complaints procedures. The home is sufficiently staffed. Staff are recruited in accordance with the Regulations. Staff receive training commensurate with their role within the home. The home is well managed. What has improved since the last inspection? There was some evidence of better recording of activities undertaken with residents but this could be developed further. The home now provides better records of food provided to residents. What the care home could do better: Where entries have to be made by hand to the medication administration records, a second person should check and sign that the entry has been entered correctly. There could be better recording of the activities carried out with residents within the daily recording notes. The home could provide improved signage around the building to assist residents in finding their way around. The wardrobes should be risk assessed and those that pose a risk of toppling should be fixed to the wall.Beechey HouseDS0000064864.V376732.R01.S.docVersion 5.2To reduce the risk of cross infection in the home, bins in the communal bathrooms should be replaced with lidded foot operated bins. Key inspection report CARE HOMES FOR OLDER PEOPLE Beechey House 14 Beechey Road Charminster Bournemouth Dorset BH8 8LL Lead Inspector Martin Bayne Key Unannounced Inspection 27th July 2009 09:00 DS0000064864.V376732.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Beechey House DS0000064864.V376732.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Beechey House DS0000064864.V376732.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beechey House Address 14 Beechey Road Charminster Bournemouth Dorset BH8 8LL 01202 290479 01202 290479 beecheyhouse@aol.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Dhanjaye Damhar Miss Nisha Devi Damhar, Mr Dhanjaye Ravi Damhar Miss Nisha Devi Damhar Care Home 16 Category(ies) of Dementia - over 65 years of age (16), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (16) Beechey House DS0000064864.V376732.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Any residents accommodated on the second floor must not be dependent on staff to evacuate the building. The schedule of requirements must be completed within the agreed timescales. 29th July 2008 Date of last inspection Brief Description of the Service: Beechey House is a large detached property, situated in the Charminster area of Bournemouth. Beechey House is registered under Mr Dhanjaye Damhar, his daughter Miss Nisha Devi Damhar and his son Mr Dhanjaye Ravi Damhar. Miss Damhar is the registered manager responsible for the day-to-day running of the home. A maximum of 16 people can be accommodated there. The home is within walking distance of the local shopping area of Charminster, local buses are available close to the home to travel to nearby towns, including Poole and Bournemouth. The property is set back from the road and approached via a short driveway. On street parking is available for visitors. A secluded garden at the rear of the property is accessible to residents. Beechey House is registered to accommodate people over age 65 who have dementia or a mental disorder. The accommodation is arranged over three floors, with a passenger lift available to assist access between floors. There are 15 bedrooms (one shared room), all bedrooms have a wash hand basin and 12 bedrooms have ensuite toilet facilities. A lounge/dining room is available to residents and is on the ground floor. Weekly fees (reviewed at least annually) range from £492.00 to £505.00. Fees include all care and accommodation costs, including meals, laundry and activities. Additional charges are made for hairdressing, dry cleaning and chiropody. People are expected to pay for their own personal items such as private telephone, toiletries and newspapers. General information about fees and fair terms of contracts can be accessed from the Office of Fair Trading web site at www.oft.gov.uk. The home hold a copy of the most recent inspection report, which is available, on request. Beechey House DS0000064864.V376732.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. We, the Commission, carried out a key inspection of Beechey House residential home between 9:45am and 2:15pm. The inspection was carried out by one inspector, but throughout the report the term we is used, to show that the report is the view of the Care Quality Commission. The aim of the inspection was to evaluate the home against key National Minimum Standards for older persons, and to follow up on two requirements and two recommendations made at the last key inspection of the home in July 2008. We were assisted throughout the inspection by the homes Registered Manager who provided us with samples of records that the home is required to maintain on behalf of its residents. During the inspection we spoke with two members of staff, a visiting GP, a member of the community mental health team and a friend of one of the residents. Throughout much of the inspection we sat in the main lounge and had the opportunity to speak with many of the residents. Owing to their mental frailty many were unable to give an account of what it was like to live at the home. Additional information that helped form the judgements contained within this report was obtained from the Annual Quality Assurance Assessment document completed by the home. What the service does well: The home carries out pre-admission assessments of need for people who wish to move to the home, to make sure that these can be met at the home. Residents health and social needs are met through good care planning and risk assessment. The home works closely with health colleagues. Medication is administered in line with good practice. Residents are treated with respect and dignity. Beechey House DS0000064864.V376732.R01.S.doc Version 5.2 Page 6 Residents can receive visitors at any time. The home provides a good standard of food. The home has well publicised complaints procedures. The home is sufficiently staffed. Staff are recruited in accordance with the Regulations. Staff receive training commensurate with their role within the home. The home is well managed. What has improved since the last inspection? What they could do better: Where entries have to be made by hand to the medication administration records, a second person should check and sign that the entry has been entered correctly. There could be better recording of the activities carried out with residents within the daily recording notes. The home could provide improved signage around the building to assist residents in finding their way around. The wardrobes should be risk assessed and those that pose a risk of toppling should be fixed to the wall. Beechey House DS0000064864.V376732.R01.S.doc Version 5.2 Page 7 To reduce the risk of cross infection in the home, bins in the communal bathrooms should be replaced with lidded foot operated bins. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Beechey House DS0000064864.V376732.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beechey House DS0000064864.V376732.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from having their needs assessed before being offered a place at the home and this ensures that the home can meet the needs of the people it admits into residential care. EVIDENCE: Throughout the inspection we used a sample of three residents personal files to track the records that are required to be kept up to date by the Care Homes Regulations 2001. All three of these residents had been admitted to the home since the last key inspection in July 2008. We found that the Registered Manager had completed a pre-admission assessment form of these residents needs prior to their being offered a place at the home. The template that the home uses to record the pre-admission assessment of need, covered all of the Beechey House DS0000064864.V376732.R01.S.doc Version 5.2 Page 10 topics that are detailed within the National Minimum Standards for older people. The returned AQAA informed us of the homes procedures for admitting new residents. All prospective residents or their friends and family are asked to view the home and given a copy of the homes Statement of Purpose and Service User Guide to ensure that they are informed of the services provided at the home. When residents are referred through care management arrangements, we saw that the home obtains a copy of these assessments from the referring social worker. Beechey House DS0000064864.V376732.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from their health needs being met through good care planning and assessment. Medication was found to be administered in line with good practice and residents are treated with respect and dignity. EVIDENCE: We looked out the personal care files for the three residents we tracked through the inspection. We found a photograph on the front of each persons file, which is good practice in assisting staff to be able to identify residents. When a person is admitted into Beechey House, we saw that a range of assessments are carried out. These included; personal information details, an assessment concerning physical health, skincare, mental health, behavioural needs, nutrition, a falls risk assessment and a moving and handling assessment as well as a short social history of each resident. We saw that Beechey House DS0000064864.V376732.R01.S.doc Version 5.2 Page 12 care plans are then developed from these assessments to inform staff on how to care for each individual. We found good care plans that identified residents needs, objectives and how the staff were to support residents to meet these objectives. There was evidence of care plans being reviewed each month to ensure that they are kept up to date. Owing to the mental frailty of all the residents accommodated at the home, they were unable to be involved in their care development, but we did see examples of where relatives had been involved. By looking at the care plans and the daily recording notes completed by the staff, we found evidence that residents health care needs were being appropriately managed. The visiting GP we spoke with told us that there was good communication between the home and the surgery. They also told us that when they visited the home, staff would ensure that consultations were held in the privacy of a residents bedroom. The member of the community mental health team with whom we spoke, told us that the home had worked in accordance with an agreed action plan in meeting one particular residents challenging behaviour needs. We also saw that residents other health-care needs, such as chiropody, dentistry and visits to opticians were arranged. Throughout the inspection we were able to observe the interaction between the staff and the residents and there appeared to be good relationships between the two. During the lunchtime period we observed staff assisting some residents in an appropriate and patient manner. We also observed two residents being hoisted correctly with staff speaking to the residents calmly on how they were to assist them. The friend of one of the residents with whom we spoke, told us that they had been very pleased with the care provided at Beechey House and they told us that staff treated residents with respect and dignity. We looked at how medication was being administered within the home. On account of the mental frailty of all the residents, all medication is administered by the staff. The home has a medication trolley that is kept locked within the dining area and there is also a controlled drugs cabinet that meets new Regulations for the storage of any controlled drugs. We were told that all of the staff who administer medication have received training in safe medication administration. We saw within the medication administration record folder, a sheet with the names of staff trained to administer medication together with a sample of their signature. This is good practice. We also saw other good practice of any known allergies of particular residents being recorded at the top of their medication administration records. We looked at the medication administration records for all of the residents and these were being completed in full with no gaps within the recording. At the last inspection we recommended that where hand entries are made to the medication administration records, these are checked and signed by a second member of staff to ensure that there has been no error in transcribing information. We saw examples of this practice having been adopted but not in all cases. We Beechey House DS0000064864.V376732.R01.S.doc Version 5.2 Page 13 recommend that this practice is adopted in all cases where hand entries are made to the records. We checked the amounts of a controlled drug being held for one resident and this tallied with the record contained in the controlled drugs register. Beechey House DS0000064864.V376732.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from their leisure and recreational needs being met, from having access to their friends and relatives and through being offered a good standard of food. EVIDENCE: As already mentioned within the report, the home seeks information from relatives about residents life histories, so as to be able to meet their recreational and leisure needs. When we spoke with staff it was evident that they knew the likes and dislikes and personal preferences of each resident. We were told that each week there are two external providers who visit the home to carry out activities with residents; an accordion player and a person who undertakes games and craft activities. On the day of our visit we saw that staff spent individual time talking with residents attending to their needs. We saw that one person was provided with a daily newspaper, another resident was busy with embroidery and another person was provided with a comfort toy Beechey House DS0000064864.V376732.R01.S.doc Version 5.2 Page 15 that they liked to carry around with them. At that the last key inspection we recommended that that staff make more references in the daily recording of individual time and activities undertaken with residents. Whilst we saw some evidence of activities being recorded we again recommend that there is more evidence of activities provided to residents. The friend of the resident we spoke with told us that they were always made welcome at the home and that they could visit at any time unannounced. We saw as part of the initial assessment when a person moves into the home, their religious and cultural needs are assessed. We found there were no unmet spiritual needs of residents accommodated at the home. At the last key inspection we recommended that more detailed recording be made of food provided to residents to evidence that individuals tastes were being met. We looked at the records of food provided to residents and found that these were now much more detailed. From these records it was possible to determine what each resident had been provided with. We found that although there was generally a limited choice of meals at lunch time, the home knew residents dislikes and alternative meals were provided for residents who did not like the main meal that was being provided. We saw that a nutritional assessment is carried out when a person moves into the home and that their weight is recorded every six months. Should the person be subject to weight loss, the home users the MUST tool, (malnutrition universal screening tool), to look at how nutritional needs can be met. We saw evidence of residents being prescribed build-up drinks to enhance their calorie intake when they had been losing weight. Beechey House DS0000064864.V376732.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from a well-publicised complaints procedure and full policies and procedures relating to the safeguarding of vulnerable adults. They also benefit from the staff receiving training in recognizing abuse and its prevention. EVIDENCE: We were told that since the last key inspection July 2008, no formal complaints had been made to the management of Beechey House. There have also been no concerns or complaints brought to the attention of the Commission within that period. The complaints procedure for the home is displayed in the front reception and is also within the homes Service User Guide as well as the terms and conditions of residence. Relatives and people who visit the home are therefore well-informed of how to make formal complaints. We were told that the home has all relevant policies and procedures relating to the safeguarding of vulnerable adults and that these link in with the local social services protocols. All of the staff receive training in the protection of vulnerable adults. Beechey House DS0000064864.V376732.R01.S.doc Version 5.2 Page 17 Beechey House DS0000064864.V376732.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Beechey House provides a homely and comfortable environment for residents. EVIDENCE: As part of the inspection we carried out a tour of the premises. Beechey House provides a comfortable and homely environment for residents with adequate communal facilities and access to an enclosed garden at the rear of the home. The upper floors of the home are accessed by passenger lift or stairways. We saw that grab rails are fitted in the corridors to assist residents with limited mobility. Although we found there was some signage throughout the building, we recommend that the home consider improving signage as the home has a complicated layout for people with dementia. We also saw that some Beechey House DS0000064864.V376732.R01.S.doc Version 5.2 Page 19 bedrooms had the name and photograph of the resident concerned displayed on their door but not in all cases. We found the home to be clean with furniture and fittings in a good state of repair. Generally the decor was in reasonable order. The Registered Manager told us that there were plans for the redecoration of some areas of the building, for instance the living room where in some areas wallpaper was coming away from the walls. We looked in some residents’ bedrooms and saw that they were able to personalise their rooms with their own furniture and possessions. We found that wardrobes were not fixed to the wall and some could pose a risk of toppling. We recommend that wardrobes be risk assessed and fixed to the wall if they pose such a risk. We saw the window restrictors are fitted to ensure that residents cannot fall from windows above ground level. We saw that all radiators have been covered to protect residents from the risks of hot surfaces and that thermostatic mixer valves have been fitted to hot water outlets in bathrooms to protect residents from scalding hot water. The home has a laundry area that is accessed away from food preparation areas. The laundry room is fitted with commercial machines that can meet the laundry needs of the home. The laundry area has hand washing facilities and we saw that walls and floor surfaces were sealed and easily cleanable. We saw throughout the inspection that staff were provided with gloves and protective aprons to promote good infection control measures. We would recommend however that the bins in the communal bathrooms be replaced with foot operated lidded bins to reduce the risks of cross infection in the home. Beechey House DS0000064864.V376732.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit by there being suitable staffing levels and by the staff being appropriately trained and recruited. EVIDENCE: We discussed the staffing levels provided at the home and were shown copies of duty rosters. These informed that the following care staff were on duty: 7:30 a.m. to 8 a.m. five care staff, 8 a.m. to 6:30 p.m. three care staff, 6:30 p.m. to 8 p.m. two care staff and between 8 p.m. and 9 p.m. four staff. During the night-time period there are two members of staff who carry out awake night duties. We were told that this level of staffing met the needs of the current residents accommodated. The friend of the resident with whom we spoke also agreed that this level of staffing met the needs of the residents. The home has a core of staff who have worked for a long time at the home and since the last key inspection only one new member of staff has been appointed to the care staff team. We looked at the recruitment records of this member of staff and we found that all the recruitment checks as required under Schedule 2 of the Care Homes Regulations 2001 have been complied with. Beechey House DS0000064864.V376732.R01.S.doc Version 5.2 Page 21 The home has a complement of 11 permanent staff members six of whom have completed NVQ level 2 training. The home therefore provides a level above 50 of the staff training to NVQ level 2 or above. Concerning staff training, we spoke with one of the domestic staff who told us that they had been provided with all relevant training commensurate with their role as cleaner. This included training in COSHH, (control of substances harmful to health) and moving and handling training. We also spoke with the newly appointed member of staff who told us that they had received induction training and training in core fields. We looked to a sample of staff training records and saw the staff are trained in or subjects, such as, moving and handling, fire safety, adult protection, first aid and basic food hygiene. We also saw that refresher courses were planned over the next coming months. Beechey House DS0000064864.V376732.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed and run in the interests of the residents. EVIDENCE: The Registered Manager has over five years experience in managing a residential care setting and has achieved the Registered Managers Award. The recommendation made at the last key inspection in July 2008 remains in place as the Registered Manager is still yet to complete the NVQ level 4 in health and social care. Beechey House DS0000064864.V376732.R01.S.doc Version 5.2 Page 23 We were told that a recent quality assurance survey had been carried out involving relatives. To date only one questionnaire had been returned. The returned questionnaire praised the home all the good standard of care and services provided. The home does not look after any monies on behalf of residents. We looked at the accident book and saw that accidents were being recorded and analysed for trends. We looked at the fire logbook and saw that tests and inspections of the fire safety system were being carried out to the required timescales. We noted that the home was due to carry out a fire safety drill and we recommend that this is carried out as soon as possible. Beechey House DS0000064864.V376732.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X x X n/a X X 2 Beechey House DS0000064864.V376732.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP31 Good Practice Recommendations Nisha Damhar should complete her National Vocational Qualification Level 4 in Care. This recommendation has been carried forward from previous inspections. 2. OP9 We recommend that where hand entries are made on medication administration records, a second member of staff signs and checks that the record has been completed correctly. This recommendation has been carried forward from previous inspections. 3. OP12 We recommend that more detail be recorded in the daily DS0000064864.V376732.R01.S.doc Version 5.2 Page 26 Beechey House record of the time and activities that staff spend with residents, to better evidence that recreational needs of residents are being met. This recommendation has been carried forward from previous inspections. 4. OP19 We recommend that the home consider improving signage around the building to assist residents in finding their way around. We recommend that wardrobes be risk assessed and those that pose a risk of toppling should be fixed to the wall. We recommend that the waste bins in the communal bathrooms are replaced with lidded foot operated bins to maintain good infection control measures. We recommend that a fire drill is carried out as soon as possible. 5. 6. OP26 OP38 Beechey House DS0000064864.V376732.R01.S.doc Version 5.2 Page 27 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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